42 CFR §460.104

1. (a)Initial comprehensive assessment—(1) Basic requirement. The interdisciplinary team must conduct an initial in-person comprehensive assessment on each participant. The assessment must be completed in a timely manner in order to meet the requirements in paragraph (b) of this section.
   1. (2)Members present. As part of the initial comprehensive assessment, each of the following members of the interdisciplinary team must evaluate the participant in person and develop a discipline-specific assessment of the participant's health and social status:
      1. (i)Primary care provider
      2. (ii)Registered nurse.
      3. (iii)Master's-level social worker.
      4. (iv)Physical therapist.
      5. (v)Occupational therapist.
      6. (vi)Recreational therapist or activity coordinator.
      7. (vii)Dietitian.
      8. (viii)Home care coordinator.
   2. (3)Additional professional disciplines. At the recommendation of the interdisciplinary team, other professional disciplines (for example, speech-language pathology, dentistry, or audiology) may be included in the initial comprehensive assessment process.
   3. (4)Initial comprehensive assessment criteria. The initial in-person comprehensive assessment must at a minimum include the evaluation of:
      1. (i)Physical and cognitive function and ability.
      2. (ii)Medication use.
      3. (iii)Participant and caregiver preferences for care.
      4. (iv)Socialization and availability of family support.
      5. (v)Current health status and treatment needs.
      6. (vi)Nutritional status.
      7. (vii)Home environment, including home access and egress.
      8. (viii)Participant behavior.
      9. (ix)Psychosocial status.
      10. (x)Medical and dental status.
      11. (xi)Participant language.
2. (b)Development of plan of care. Within 30 days of the date of enrollment, the interdisciplinary team must consolidate discipline-specific assessments into a single plan of care for each participant through team discussions and consensus of the entire interdisciplinary team. In developing the plan of care:
   1. (1)If the interdisciplinary team determines that certain services are not necessary to the care of a participant, the reasoning behind this determination must be documented in the plan of care.
   2. (2)Female participants must be informed that they are entitled to choose a qualified specialist for women's health services from the PACE organization's network to furnish routine or preventive women's health services.
3. (c)Semi-annual reassessment. On at least a semi-annual basis, or more often if a participant's condition dictates, the following members of the interdisciplinary team must conduct an in-person reassessment:
   1. (1)Primary care provider.
   2. (2)Registered nurse.
   3. (3)Master's-level social worker.
   4. (4)Other team members that the primary care provider, registered nurse and Master's-level social worker determine are actively involved in the development or implementation of the participant's plan of care.
4. (d)Unscheduled reassessments. In addition to semi-annual reassessments, unscheduled reassessments may be required based on the following:
   1. (1)A change in participant status. If the health or psychosocial status of a participant changes, the members of the interdisciplinary team listed in paragraph (c) of this section must conduct an in-person reassessment.
   2. (2)In response to a service determination request. In accordance with § 460.121(h), the PACE organization must conduct an in-person reassessment if it expects to deny or partially deny a service determination request, and may conduct reassessments as determined necessary for approved services.
5. (e)Changes to plan of care. When the interdisciplinary team conducts semiannual or unscheduled reassessments, the interdisciplinary team must reevaluate and, if necessary, revise the plan of care in accordance with § 460.106(c) following the completion of all required assessments.
6. (f)Documentation. Interdisciplinary team members must document all assessment and reassessment information in the participant's medical record.